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Quote of the Month
"I believe in human dignity as the source of national purpose, human liberty as the source of national action, the human heart as the source of national compassion, and in the human mind as the source of our invention and our ideas"
John Fitzgerald Kennedy
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Joint Commission Alert: Effective Leadership Critical to Preventing Medical Errors
(OAKBROOK TERRACE, Ill. - August 27, 2009)
A new Joint Commission Sentinel Event Alert issued today urges health care leaders to step up efforts to prevent errors by taking the zero-defect approach used in other high-risk industries such as aviation and nuclear energy. The Joint Commission is advocating greater involvement of health care trustees, executives, and physician leaders, contending that the overall safety and effectiveness of a health care facility depends on administrative and clinical leaders who set the tone, create the culture and drive improvements. In safe organizations, safety is rooted in the culture and the system, rather than in the behavior of individuals.
"Health care leaders are directly responsible for establishing a culture of safety," says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. "This Alert provides leaders with concrete strategies for demonstrating a commitment to safety and to improving patient outcomes."
To improve patient safety, The Joint Commission's Sentinel Event Alert recommends that the governing body, chief executive officer, senior managers and medical staff leaders at health care organizations take a series of 14 specific steps, including the following:
- Define and establish an organization-wide safety culture that includes a code of conduct for all employees.
- Institute an organization-wide policy of transparency that sheds light on all adverse events and patient safety issues.
- Make the organization's overall safety performance a key, measurable part of the evaluation of the CEO and all leadership.
- Ensure that caregivers involved in adverse events that result in unintentional patient harm receive attention that is just, respectful, compassionate, supportive and timely.
- Create and communicate a policy that defines behaviors that are to be referred for disciplinary action and a timeframe for that action to take place.
- Add a human element to safety improvement by having patients communicate their experiences and perceptions to leadership.
- Reward and recognize staff whose efforts contribute to safety.
In addition to specific recommendations contained in the Alert, The Joint Commission urges health care organizations to use the Leadership section of its accreditation standards to improve patient safety. The standards require organizational leaders to create a culture of safety and to provide the resources necessary for patient safety. The standards also cover reporting systems for adverse events and near misses and the design of processes to support safety.
The emphasis on the role of leadership in promoting greater patient safety is part of a series of Alerts issued by The Joint Commission. Much of the information and guidance provided in these Alerts is drawn from the Joint Commission's Sentinel Event Database, one of the nation's most comprehensive voluntary reporting systems for serious adverse events in health care. The database includes detailed information about both adverse events and their underlying causes. Previous Alerts have addressed health care technology, anticoagulants, wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others topics. The complete list and text of past issues of Sentinel Event Alert are available on The Joint Commission Web site.
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"It may be that your whole purpose in life is simply to serve as a warning to others."
Unknown
"Many organizations have little sense of purpose beyond their own sense of organization."
Unknown
"The secret to success is consistancy to purpose."
Benjamin Disraeli
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| Coming
Soon!
A new "Focus" on hospital improvement.
Hospital Focus5 | |
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WHAT'S YOUR PURPOSE?
Please read the article called A Dog's Purpose below. It was sent to me by Owen H. Lucas, MD, MMM in Indianapolis, IN.
As humans in human created organizations, we are blessed and cursed by not having an obviously set purpose already established for us Of course the upside is that we get to develop, to choose our purpose. Will we be as smart as a dog?
Organizations have a huge responsibility to be at least as smart as dogs and this responsibility is too often misunderstood, ignored and/or grossly underestimated. I believe that hospitals and other healthcare institutions should have a very easy time with purpose. Is their purpose to make money? Well, they do need to survive to provide care another day. Is their purpose to experiment on us? Well, they do need to advance medicine Is their purpose a truly noble one? Well, they do care for us when we need help the most, when we are the most joyful and the most vulnerable - at the beginning and the end of our lives.
I suggest that Boards of Directors and other leaders take time to regularly review their organization's (and their own as board members) purpose. It should be easy, just start with a big woof!
Last month I talked about the lack of passion in too many key areas of healthcare. One of my concerns centers around physicians. What if they become less passionate about their work? Many of them seem to feel like Carrie Fisher. On a recent Late, Late Show with Craig Ferguson she said "Things are getting worse faster than I can lower my standards." Not a good situation, is it?
Read the email I received from a surgeon, I copied it below and printed it with the doctor's permission. As I said to him, we're in big trouble if we lose the physicians' passion. Then read about a recent Emergency Room experience. Do you think we've lost the passion and a purpose? Email me with your thoughts.
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A Dog's Purpose
Author unknown
Being a veterinarian, I had been called to examine a ten-year-old Irish Wolfhound named Belker. The dog's owners, Ron, his wife Lisa, and their little boy Shane, were all very attached to Belker, and they were hoping for a miracle.
I examined Belker and found he was dying of cancer. I told the family we couldn't do anything for Belker, and offered to perform the euthanasia procedure for the old dog in their home.
As we made arrangements, Ron and Lisa told me they thought it would be good for six-year-old Shane to observe the procedure. They felt as though Shane might learn something from the experience.
The next day, I felt the familiar catch in my throat as Belker 's family surrounded him. Shane seemed so calm, petting the old dog for the last time, that I wondered if he understood what was going on. Within a few minutes, Belker slipped peacefully away.
The little boy seemed to accept Belker's transition without any difficulty or confusion. We sat together for a while after Belker's Death, wondering aloud about the sad fact that animal lives are shorter than human lives. Shane, who had been listening quietly, piped up, ''I know why.''
Startled, we all turned to him. What came out of his mouth next stunned me. I'd never heard a more comforting explanation. It has changed the way I try and live.
He said,''People are born so that they can learn how to live a good life -- like loving everybody all the time and being nice, right?'' The six-year-old continued,''Well, dogs already know how to do that, so they don't have to stay as long.''
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Email From a Cardiac Surgeon
Topic: Passion
PHYSICIAN: If you wanted to drum passion out of what was once a noble and proud profession, you'd have the hospitals buy the physicians' practices for reasons only related to market share.
KEN BAST: If we lose the passion of the physicians, we're in even bigger trouble than we are now!
PHYSICIAN: It's lost. Most I know in their 50's are gone, counting the days, or out of gas without passion. Some in their 40's aren't as down, but realize a totally different environment. Those in 30's are newbies, and it's a different world. More like shift work in a large factory. Special relationships between doctor and patient are absent or have eroded. Not to sound like there's no passion or relationship whatsoever, but by buying doctors and "managing" their practices (and most specifically their referral patterns), they have taken away the collegiality, the drive to go the extra mile, and the focus off the patient.
I don't know how many stories I have told about this. It is absolutely shocking to patients that the specialist to whom they are referred is highly dependent on who owns the primary care doc. No longer does the finest physician "earn" the referral due to clinical excellence and service to the primary doctors. Administrators are now buying up specialists. Who do you think agreed to be bought first? Right, the ones without a strong referral base, often because they aren't the best. Now the best ones, who tried hard to stay independent, are being approached by the hospital administrators with the phrase, "Do you wish to be employed, or do you wish to be unemployed?"
Many scary stories here. Your wife, or your mother, or your daughter may well end up in the hands of a "hack" because he or she is owned by a system and the better docs are labeled off limits to the primary docs. I know, as I lost an entire hospital to that phenomenon.
And well beyond that, how long before young physicians in training realize that the way to get patients has nothing to do with clinical excellence, but being part of a large organization that funnels them to you because you are the guy in the "Thursday" on call seat. How long before excellence and pride are immaterial. Yes, transparency will have some effect on that, but that's a long way off. I'm seeing hospitals rated for all sorts of stuff, and while I might very well want to go to get my bypass operation at a given place, I certainly wouldn't want to have a baby there or get a complex medical condition. Communication, teamwork, and the drive to answer the really tough problems are things of the 80's.
And finally (not really, there's plenty more where all of this came from), 2% of the graduates of US med schools in 2008 went into internal medicine or family practice. The cardiovascular surgery fellowship programs are only 1/2 full. Who's going to take care of us? The dermatologists, anesthesiologists, and ophthalmologists?
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Are You Mad at Us?
A client of mine had occasion recently to take her teenage daughter to a hospital emergency room on the instruction of her physician. Without going into great detail, her daughter had been vomiting for multiple hours and nothing seemed to stop that process. Upon arrival they were greeted with a friendly "You came to the ER for vomiting?" After explaining multiple times that the condition came about with no apparent reason and would not go away and that their family physician told them to come to the ER, they were told "well you'll just have to wait until we can fit you in."
While waiting in the large waiting area the teenager was still vomiting, but it took her mother asking for something to vomit into before anyone paid any attention. Finally, after some amount of time they were escorted to a treatment cubical. There they received such curt treatment from the nurse that the patient's mother (my client) asked "are you mad at us?" The nurse responded with a one word "what?" Mom replied "are you mad at us for coming to your emergency room?" At that point the nurse replied that "no she wasn't, but they were really busy."
After spending nine (9) hours in the ER, the teen was sent home with instructions to see her family physician. Mom was able to talk directly with the physician and was told to bring her daughter in the next day at 9:15 AM. Arriving at 9:15 AM mother and daughter were told multiple times by the office staff that "they weren't on the appointment list." After responding multiple times that yes, they were aware of this, but the doctor had told them to come in at 9:15, the staff told them "well you'll just have to wait until we can fit you in." Fortunately, five minutes later they saw the doctor.
Aside from the clinical question "what's wrong with my daughter?" And "can you help us?" the "Are you mad at us?" really goes to the core of the issue. How many ERs and other hospital departments make patients feel that they are unwelcome there?
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